(101) A Quality Initiative to Decrease Intervention Times for Neonatal Post-hemorrhagic Ventricular Dilatation

Background: Frontal-occipital horn ratio (FOHR) in preterm infants with post-hemorrhagic ventricular dilatation (PHVD) following intraventricular hemorrhage (IVH) correlates with function at school age. Earlier neurosurgical intervention may lead to improved outcomes. The Hydrocephalus Clinical Research Network proposes using a threshold FOHR 0.55 and signs of increased intracranial pressure to consider cerebrospinal fluid (CSF) diversion. Prior to this quality initiative (7/2021) with the goal of decreasing FOHR for Neurosurgery consult to 0.50 and consideration of intervention to 0.55, mean FOHR at our academic level IV NICU was 0.62 at consult and 0.75 at first intervention. By 9/2022, these had improved to 0.48 and 0.71, respectively, with FOHR 0.67 at consideration of intervention.

Objectives: To assess continued impact of this initiative on time to neurosurgical consult and intervention.

Design/Methods: We continued to assess the tools we had developed: quantitative head ultrasound (HUS) order, electronic health record (EHR) flowsheet to calculate and document FOHR during clinical workflow, and EHR clinical decision support (CDS) tool integrated into clinician progress notes. Process measures included rates of use of these tools. Outcome measures included FOHR at time of consult, consideration of intervention (assessed by review of clinical notes), and CSF diversion. The balancing measure was consults not resulting in intervention. Data from 10/2022-1/2023 was analyzed. Data collection 2/2023-present is ongoing.

Results: In the second epoch, of 19 preterm infants with IVH, 12/19 infants had grade I/II IVH, and 7/19 infants had grade III/IV IVH. Rate of appropriate use of the HUS order was 100%, previously 89%. Flowsheet was used at a very high rate, but CDS tool was minimally used. Of patients with IVH, 10 had a Neurosurgery consult and 6 were considered for intervention, compared to 14 and 3, respectively, in the prior epoch. Average FOHR was 0.51at neurosurgical consultation, 0.56 at consideration for intervention, and 0.61at CSF diversion, respectively. The balancing metric of consults not resulting in intervention was 60%.

Conclusions: We achieved persistent success of neurosurgical consult at goal FOHR. FOHR at consideration of and actual intervention improved compared to previously. Delay between consideration for and actual intervention are due to clinical factors that raise surgical risk. Future assessments will include rates of ventriculoperitoneal shunt and neurodevelopmental impairment.